1. The 2009 Physician Quality Reporting Initiative (PQRI) American Academy of Orthopaedic Surgeons American Association of Orthopaedic Executives May 19, 2009 Sylvia W. Publ, MBA, RHIA CMS Sr. Quality Advisor Consortium for Quality Improvement and S&C Operations, CQISCO

2. 2 Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. CPT only copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

3. 3 Overview Value-Based Purchasing and PQRI PQRI Reporting: Measures & Codes Implementing PQRI 2009 E-Prescribing Incentive Resources

4. 4 VBP Towards Value-Based Purchasing 2007 TRHCA 74 measures Claims- based only 2008 MMSEA 119 measures Claims 4 Measures Groups Registry 2009 MIPPA 153 measures Claims 7 Measures Groups Registry EHR- testing eRx 2010 TBD through rule- making

5. 5 PQRI Claims-Based Process Visit Documented in the Medical Record Encounter FormCoding & Billing Carrier/MAC NCH Analysis ContractorNational Claims History File Incentive Payment Confidential Report Critical Step N-365

6. 6 2009 PQRI Measures/Codes Downloadable Resources http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopO fPage 2009 PQRI Measures List : measure developer, reporting method Reporting Individual Measures via Claims - 2009 PQRI Measures Specifications Manual for Claims and Registry and Release Notes - 2009 PQRI Implementation Guide Reporting Measures Groups - 2009 PQRI Measures Groups Specifications Manual - 2009 PQRI Getting Started in Reporting of Measures Groups

7. 7 2009 PQRI Resources http://www.cms.hhs.gov/PQRI/20_Reporting.asp#TopOfPage Registry-based Reporting - Individual Measures (at least 3 or more) - Measures Groups List of Qualified Registries (additional registries qualifying) http://www.cms.hhs.gov/PQRI/30_EducationalResources.asp#TopOf Page MLN Matters Articles Fact Sheets Tip Sheets 2009 PQRI Patient-Level Measures List

8. 8 Claims-Based Reporting Principles The CPT Category II code(s) and/or G-code(s), which supply the numerator, must be reported: - on the same claim - for the same beneficiary - for the same date of service (DOS) - for the same EP (NPI within the holder of the tax ID number - NPI/TIN) All diagnoses reported on the base claim will be included in PQRI analysis. Claims may NOT be resubmitted simply to add or correct QDCs. QDCs must be submitted with a line-item charge of zero dollars ($0.00) at the time the associated covered service is performed. If a system does not allow a $0.00 line-item charge, a nominal amount can be substituted. The submitted charge field cannot be blank.

9. 9 Claims-Based Reporting Principles (ctd.) Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00). QDC line items will be denied for payment by the carrier, but are then passed through the claims processing system for PQRI analysis. EPs will receive a Remittance Advice (RA) associated with the claim which contains the PQRI QDC line- item that will include a standard remark code (N365) and a message that confirms that the QDCs passed into the National Claims History (NCH) file. N365 reads: This procedure code is not payable. It is for reporting/information purposes only. The N365 remark code does NOT indicate whether the QDC is accurate for that claim or for the measure the EP is attempting to report.

10. 10 CMS-1500 Claim Example Example of an individual NPI reporting on a single CMS-1500 claim. See http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf for more information. http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease (CAD), and urinary incontinence: Measure #2 (LDL-C) with QDC 3048F + diabetes line-item diagnosis (24E points to DX 250.00 in Item 21); Measure #3 (BP in Diabetes) with QDCs 3074F + 3078F + diabetes line-item diagnosis (24E points to Dx 250.00 in Item 21); Measure #6 (CAD) with QDC 4011F + CAD line-item diagnosis (24E points to Dx 414.00 in Item 21); and Measure #48 (Assessment - Urinary Incontinence) with QDC 1090F. For PQRI, there is no specific diagnosis associated with this measure. Point to the appropriate diagnosis for the encounter. Note: All diagnoses listed in Item 21 will be used for PQRI analysis. Measures that require the reporting of two or more diagnoses on claim will be analyzed as submitted in Item 21. NPI placement: Item 24J must contain the NPI of the individual provider that rendered the service when a group is billing. This includes putting the individual NPI on the QDC line-items as well. The Tax ID associated with the NPI(s) on this claim is shown in Item 25. CAD BP< 80 mmHg–PQRI #3 UI Assessed–PQRI #48 CAD–PQRI #6 BP<130 mmHg–PQRI #3 AND DM–PQRI #2 24D. Procedures, Services, or Supplies – CPT/HCPCS, Modifier as needed For group billing, the rendering NPI number of the individual EP who performed the service will be used from each line-item in the PQRI calcula- tions. QDC codes must be submitted with a line-item charge of $0.00. Charge field cannot be blank. Identifies claim line-item Solo practitioner - Enter individual NPI here 21. Review applicable PQRI measures related to ANY diagnosis (Dx) listed in Item 21. Up to 8 Dx may be entered electronically. Diabetes Mellitus 10

11. 11 How to Get Started Gather information from the PQRI web page: www.cms.hhs.gov/pqri (e.g., Measures/Codes, Educational Resources, Tool Kit web pages)www.cms.hhs.gov/pqri Gather information from other sources, such as your professional association, specialty society, or the American Medical Association Determine which PQRI reporting option(s) best fits practice Determine PQRI reporting period

12. 12 Selection of Measures Consider Practice Characteristics: - Clinical conditions usually treated - Types of care typically provided – e.g., preventive, chronic, acute - Settings where care is usually delivered – e.g., office, ED, surgical suite - Quality improvement goals for 2009 Review the List of Measures: determine which measures apply most frequently to the practice's Medicare FFS patients. Many PQRI measures require one-time reporting per patient per reporting period per eligible professional (See Patient Level Measures List). Review 2009 PQRI Measures Specifications Manual for Claims and Registry & Release Notes for selected measures carefully to understand reporting instructions, coding, and frequency of reporting.

13. 13 Selection of Reporting Method Review and study the measures specifications: Measures Specifications Manual for Claims and Registry & Release Notes for selected measures carefully to understand reporting instructions, coding and frequency of reporting. Select a reporting method: via claims or via a qualified registry The 2009 PQRI Participation Decision Tree is a tool designed to help practices select a reporting method (see Appendix 2009 PQRI Implementation Guide)

14. 14 Prepare to Participate in PQRI Assemble an Implementation Team - Ensure that the practice's billing software and clearinghouse can capture all the codes and associated modifiers used in PQRI for the measures you have selected. Discuss with EDI vendors. - Read and discuss with staff: reporting principles and specifications for each of the measures selected for reporting in PQRI.

15. 15 Prepare to Participate in PQRI Develop a process for concurrent data collection so that all eligible claims and PQRI quality data codes (QDC) are correctly identified and submitted Regularly review the Remittance Advice notices from the Carrier/AB MAC to ensure you receive N365 remark code for each QDC submitted

16. 16 2007 PQRI Experience Report Invalid QDC Submission Attempts 12.15% Missing individual NPI 18.89% Incorrect HCPCS (CPT1) code* 13.93% Incorrect DX code* 7.24% Both incorrect HCPCS code and incorrect DX code* 4.97% All line items were QDCs only *Denominator mismatch http://www.cms.hhs.gov/PQRI/Downloads/2008QDCError3rdQuar ter.pdf

17. 17 Contributing Factors Split claims Diagnosis Pointer Missing NPI QDC reported on denied claim Missing QDC on eligible claim (eg, incident to billing) Shared codes (#7, #8) (#8 changed to G codes for 2008)

18. 18 2008 PQRI Aggregate QDC Error Report – Osteoporosis Measure# Submitted%Valid #24 Communication post Fx 9,56451.18% #39 Screening Osteoporosis 190,24881.48% #40 Mgmt Following Fx232,377 1.53% #41 Pharmacologic Therapy 111,10243.92% http://www.cms.hhs.gov/PQRI/Downloads/2008QDCError3rdQuarter.pdf *Jan-Sept 2008, Post-Analytic Fix

19. 19 2008 PQRI Aggregate QDC Error Report –Perioperative Measures* Measure# Submitted%Valid 20 Timing Prophylaxis Antibiotic1,168,64113.42% 21 Selection Prophylactic Antibiotic143,50881.07% 22 Discontinuation Prophylactic Antibiotic 133,26365.52% 23 VTE Prophylaxis95,94074.59% http://www.cms.hhs.gov/PQRI/Downloads/2008QDCError3rdQuarter.pdf * Jan-Sept 2008, Post-Analytic Fix

20. 20 Common Errors Missed reporting QDC on eligible claim (e.g., incident to claims) Reporting a QDC on a claim for a diagnosis that was not listed in the denominator for the measure Reporting a QDC on a claim with an office visit code when the measure required a surgical procedure code or a consultation code Reporting a QDC on a claim when the diagnosis and the CPT 1 service were not listed in the denominator for the measure Reporting one QDC when the claim requires two QDCs Reporting one Dx on a claim when two Dxs should to be reported Reporting a QDC with a CPT1 modifier Reporting a QDC on a claim for a service that was not covered by Medicare (or claim was denied by carrier). Individual rendering NPI was not listed on the claim, therefore, that claim was not included in PQRI analysis

21. 21 Benefits of PQRI Participation Receive confidential feedback reports to support quality improvement Earn a bonus incentive payment Make an investment in the future of the practice - Prepare for higher bonus incentives over time - Prepare for pay-for-performance - Prepare for public reporting of performance results

22. 22 Resources: PQRI Website www.cms.hhs.gov/pqri

23. 23 FAQs, Listserv

24. 24 Centers for Medicare & Medicaid Services 2009 E-Prescribing Incentive Program Resources : http://www.cms.hhs.gov/ERXIncentive - Measure Specifications - Claims-Based E-Rx Reporting Principles - Sample E-Prescribing Claim

25. 25 How the E-Prescribing Incentive Program Works Denominator-eligible Encounter Documented in Medical Record & e-Rx Generated Encounter Form Coding & Billing Carrier/MAC Analysis Contractor NCH National Claims History File Successful e-prescriber =Incentive Payment Confidential Report for e-prescriber Critical Step E-Rx Trans- mitted to Pharmacy N-365 PBM

26. 26 What is Not E-Prescribing Calling in a prescription Patient seen in ED is sent home with a written prescription Physician-generated faxed prescription to receiving pharmacy fax Sending a prescription via PDA (exception: depends on software used – must meet e-prescribing system qualifications) Knowingly sending a computer-generated fax initiated at the doctors office to a pharmacy (exception: if sent via qualified e- prescribing system and pharmacy system generates message as a fax, it is e-prescribing) Office visits during a global surgical period that result in a prescription Medicare Advantage patients (although you can e-Rx for these patients, MA claims do not count toward incentive payment calculation)

27. 27 Allowable Reasons for Not E-Prescribing G8446 E-Prescribing System Available, but not used for One or More Prescriptions Due to Patient/System Reasons Provider does have access to a qualified system, but due to one of the following reasons in the code descriptor, cannot e- prescribe. Only the allowable reasons delineated in the code descriptor can be applied to G8446: - Controlled substance - State, federal law - Patient asks for hard copy - Pharmacy cannot receive eRx transmittal

28. 28 Thank You For questions about PQRI or e-Rx, contact: Carrier Regional Office or Submit through the PQRI mailbox: pqri_inquiry@cms.hhs.gov For questions regarding measure construct, contact measure developer identified on 2009 PQRI Measures List